|The palliative care physician was asked by the ICU attending physician whether she might begin some discussions of end-of-life issues with a 46-year-old man in the unit who had been on a ventilator for six weeks following multiple traumas in an automobile accident. He had a T6 spinal cord injury, multiple fractures, bilateral chest tubes, bullous emphysema, and recurrent pneumonias. The ICU attending doubted that the patient could ever survive off the ventilator, and doubted that he would leave the hospital alive. Nonetheless the patient was usually alert enough to communicate by nods or mouthing words, although he could not write.|
The palliative care physician met with the patient and his wife, explaining that in the last couple of months there had been a lot of attention paid to his lungs, bones, kidneys, digestion, infections, and skin, but that she was hoping to help them take inventory on "the rest of what makes him who he is". She showed them the pack of Go Wish cards and asked the wife to show him each card and help him do the 3-category sort.
The palliative care physician came back the next day and found that in the "not important" pile were all the cards that had any mention of death. But there were plenty of cards in the very important pile, and the couple was asked to sort through the "very important" cards again for him to pick out the top ten. Later that day they worked on ranking the top ten.
Both the patient and his wife commented that the exercise had brought forth conversations that they had needed to have, but not gotten around to before that. His "wild-card" was to help his teen-age son to cope; the patient noted that his son had been left out of a lot of the prior discussions about what had been going on.
The results of his card-sort were used to identify issues that were amenable to physician/other health care provider intervention and other issues that were important to quality of life more generally. Within the top five were "to be free of pain", "not being short of breath", and "to be free from anxiety." The patient's priority for improved symptom control was communicated back to the ICU attending. The social worker was asked to arrange a family meeting that would include the son. Since preparing for death was clearly not the patient's chosen agenda, that topic was dropped, and in fact he was later successfully weaned from the ventilator and sent to an inpatient rehabilitation program.